Complex Care Nurse

Grace Health•Battle Creek, MI

1d•Onsite

About The Position

Grace Health is seeking a Complex Care Nurse to plan, arrange, provide, and evaluate health care services for patients designated as high-risk or complex per Grace Health policy. This role focuses on improving care outcomes for patients with complex medical and psychosocial chronic diseases. The position offers no weekend or holiday shifts, competitive wages, and a $1,000 sign-on bonus.

Requirements

Three years of professional nursing experience required.
Minimum three years of experience in primary care environment preferred.
Possession of a Michigan Registered Nurse license and current BLS certification

Nice To Haves

Bachelor's degree in nursing from an accredited college preferred.

Responsibilities

Applies the principles of the nursing process to improve care outcomes for complex, high-risk patients with chronic medical and psychological/behavioral diseases, through collaboration with care team providers, support staff, and behavioral health department.
Conducts chronic disease care management for high-risk/complex individual patients, and those within identified target patient sub-populations.
Conducts transitional care coordination for patients newly discharged from an in-patient setting to reduce hospital re-admission rates for Grace Health patients.
Identifies and educates patients who are high utilizers of Grace Health or emergency departments about appropriate use of services, and develops individual plans to improve appropriate use of services at those facilities.
Assess patient’s health, pain, nutritional, psychosocial, behavioral, cultural, age-specific, and learning needs.
Develops and implements plans to increase patient motivation, self-management, and self-efficacy in all aspects of chronic disease management and prevention.
Monitors quality measures related to individual and targeted sub-populations to reduce gaps in evidence-based care.
Provides referrals to community resources for patients/families.
Actively provides appropriate medical advice based on the registered nurse (RN) scope of practice.
Actively participates with community-based initiatives related to care management and transitions of care.
Safely administers medication and treatments per standard of care, organization protocols and standing orders.
Actively participates in organizational quality committees and work groups.
Participates in professional development activities and maintains professional affiliations.
Maintains required licensure and certifications.
Adeptly navigates through patient Electronic Health Records (EHR).
Participates in CLIA and OSHA compliance and monitoring.